2010 Highlighted Submissions

Each year, the HOPE Award Selection Committee is charged with the unenviable task of choosing the final winner from a wide array of outstanding submissions. The depth and breadth of the work that is being done locally, nationally, and in Canada continues to amaze and inspire us. Below are four supporting essays, submitted during the 2010 cycle, that represent the wide range of exceptional people and programs who have been nominated. If 2010 serves as any indication, we are sure you will agree that our Selection Committee has its work cut out for them!Boston Medical Center (BMC) and the Patient Advocacy ProgramBackground -- BMC is a private, not-for-profit, 639-licensed bed, academic medical center. The hospital is the primary teaching affiliate for Boston University School of Medicine. BMC emphasizes community-based care with its mission to provide consistently accessible health services to all. As the largest safety net hospital in New England, BMC provides a full spectrum of pediatric and adult care services, from primary to family medicine to advanced specialty care. With the largest 24-hour Level I Trauma Center in New England, our Emergency Department had 131,288 visits last year. As you might expect, the Patient Advocacy Program is very active and has a high volume of patient and provider interactions and is considered a priority and critical for the organization. (READ MORE)Health Care For AllIntroduction -- In 2006, health reform became law in Massachusetts. Health Care For All (HCFA), a statewide consumer health advocacy organization, was deeply involved in advocating for the law. In support of the campaign, HCFA staff conducted house meetings across Massachusetts. The organization heard many concerns about access and about the quality and cost of care. In response, HCFA started a consumer campaign for improving health care quality in the Commonwealth. The crux of this campaign would be the Consumer Health Quality Council (CHQC), a group of volunteers motivated by personal experiences and interested in crafting policy solutions to improve quality. In November 2006 the CHQC met for the first time. The CHQC Mission Statement: The mission of the Consumer Council is to empower those impacted by healthcare quality issues to have a voice in our healthcare system, to engage fellow consumers to be active partners in their healthcare, and to advocate for high quality, safe, and accessible healthcare for all Massachusetts residents.Fast-forward to the fall of 2010. The CHQC will celebrate its 4-year anniversary and can proudly look back on a number of accomplishments and look ahead to the work that still needs to be done. This essay highlights the CHQC accomplishments that directly relate to MITSS’ mission. (READ MORE)Rev. Ridley BarronIt is one think to talk about a “Just Culture” and another to espouse the idea of forgiveness. It is quite a different matter when the person “walking the talk” of adverse medical events is himself a man of faith. Such a person is Ridley Barron, now the pastor of a congregation in Tennessee.

In April 2004 Rev. Barron was the spiritual leader of a Georgia congregation. On his way home with his wife and three children from a family vacation, he was seated in the front passenger side of his vehicle. While working away at his Easter sermon, the vehicle was broad-sided by an SUV that ran a stop sign. The pastor’s wife died shortly after the impact. His two older children sustained bruises and he himself suffered fractures and other injuries. A Good Samaritan came to the family’s aid and found the pastor’s 17 month-old son several feet from the vehicle, the toddler having been ejected by the force of the impact. The toddler sustained head trauma and was taken to a pediatric center for treatment. Due to an overdose of an anti-seizure medication, the toddler died five days after the car accident. Instead of burying his wife, Rev. Barron ended up with a funeral interring two beloved family members. (READ MORE)

Beth Israel Deaconess Medical CenterIn June of 2008 Kenneth Sands MD. Sr Vice President of Health Care Quality sent an e-mail to all BIDMC employees that read in part:

“This week at BIDMC, a patient was harmed when something happened that never should happen: a procedure was performed on the wrong body part. With the support of all our chiefs of service, we are sharing this information with the whole organization because there are lessons here for all of us.

While respecting the confidentiality of both the patient and caregivers, here are the key facts: it was an elective procedure, involving an excellent team of providers. It was a hectic day, as many are. Just before hand, the physician was distracted by thoughts of how best to approach the case, and the team was busily addressing last minute details. In the midst of all this, two things happened: first, no one noticed that the wrong side was being prepared for the procedure. Second, the procedure began without performing a "time out," that last minute check where the whole team confirms "right patient, right procedure, right side." The procedure went ahead. The error was not detected until after the procedure was completed. When it was, our patient safety division was notified immediately, and they in turn took all appropriate steps including investigation, reporting, and corrective action. The physician discussed the error with the patient at the first opportunity, and made a full apology.

What a horrifying story. What important lessons. We learned that when teams are busy and distracted, it makes it easier to overlook something. We learned that key safety steps, like "the time out", need to occur every single time, since even one failure can be serious. We learned that serious events rarely relate to the performance of any single person. We learned that we have vulnerabilities that we were not even aware of, and that there are surely others out there.” (READ MORE)